Automated referral to community paramedicine during 9-1-1 fall calls for resource activation.

BACKGROUND: We sought to improve the referral process to a community paramedicine (CP) program following a 9-1-1 encounter. METHODS: An electronic health record (EHR) for CP records with the ability to link to emergency EHR was identified and implemented with a single-click referral to the CP program. Referrals were tracked for 15 months before and after implementation. RESULTS: Referral capacity increased from an average of 14.2 referrals per month to 44.9 referrals per month. CONCLUSION: The results of this study suggest an EHR is a useful investment for CP programs and may be integral to efficient program operations.

Assessment of Fall-Related Emergency Medical Service Calls and Transports after a Community-Level Fall-Prevention Initiative.

Background: Getting effective fall prevention into the homes of medically and physically vulnerable individuals is a critical public health challenge. Community paramedicine is emerging globally as a new model of care that allows emergency medical service units to evaluate and treat patients in non-emergency contexts for prevention efforts and chronic care management. The promise of community paramedicine as a delivery system for fall prevention that scales to community-level improvements in outcomes is compelling but untested.Objective: To study the impact of a community paramedic program's optimization of a fall prevention system entailing a clinical pathway and learning health system (called Community-FIT) on community-level fall-related emergency medical service utilization rates.Methods: We used an implementation science framework and quality improvement methods to design and optimize a fall prevention model of care that can be embedded within community paramedic operations. The model was implemented and optimized in an emergency medical service agency servicing a Midwestern city in the United States (∼35,000 residents). Primary outcome measures included relative risk reduction in the number of community-level fall-related 9-1-1 calls and fall-related hospital transports. Interrupted time series analysis was used to evaluate relative risk reduction from a 12-month baseline period (September 2016 - August 2017) to a 12-month post-implementation period (September 2018-August 2019).Results: Community paramedic home visits increased from 25 in 2017, to 236 in 2018, to 517 in 2019, indicating a large increase in the number of households that benefited from the efforts. A relative risk reduction of 0.66 (95% [CI] 0.53, 0.76) in the number of fall calls and 0.63 (95% [CI] 0.46, 0.75) in the number of fall-related calls resulting in transports to the hospital were observed.Conclusions: Community-FIT may offer a powerful mechanism for community paramedics to reduce fall-related 9-1-1 calls and transports to hospitals that can be implemented in emergency medical agencies across the country.

Improving blood pressure screening and control at an academic health system.

The goal of the University of California Davis Health Blood Pressure (BP) Quality Improvement Initiative was to improve the diagnosis, management and control of high BP. Patients aged 18-85 years were included in the initiative. Lean A3 problem solving was used to implement the following evidence-based interventions based on stakeholder interviews, value stream mapping and the Centers for Disease Control and Prevention's Million Hearts Initiative: staff training on accurate BP measurement, visual cues and reminders for BP screening, virtual case-based videoconferences, standardised clinical management algorithm, academic detailing visits, clinical decision support tools, access to pharmacists for medication comanagement, clinician workflow modification, patient education and access to home BP monitors. Following implementation of interventions, accurate screening of BP increased from 14% to 87% and BP control increased from 62% to 75%. Strategies that contributed the most to improvements were using a team-based approach, adjusting clinic workflow and frequent communication of results to staff.

The Financial Impact of the Affordable Care Act on a Level-1 Orthopedic Trauma Service.

OBJECTIVES: To determine the impact of the Affordable Care Act (ACA) on professional fees and proportion of payer type for an orthopedic trauma service at a level-1 trauma center. METHODS: We analyzed professional fee data and payer mix for the 18 months before and after implementation of the ACA. Data were collected for inpatients (IP) and outpatients (OP). We corrected for changes in patient volume between the 2-time periods by calculating average values per patient. RESULTS: Post ACA, we treated a higher percentage of patients with Medicaid and had a reduction in the percentage of uninsured/county payers. Collections for IPs decreased $75.49/patient and OPs decreased $0.10/patient. Our collection rate decreased 6% for IPs and 5% for OPs. In particular, Medicaid collections decreased by $180/IP, and $4/OP, and Medicare decreased by $61/IP and increased $5/OP post ACA, whereas contract collections increased by $140/IP and $20/OP. The changes in our own institution's insurance were mixed with decreases of $514/IP for partial risk and $735/IP for full-risk insurance and increases of $1/OP for partial risk, and $35/OP for full-risk insurance. CONCLUSIONS: Post ACA, we saw less patients, primarily in the OP setting. This shift was accompanied by a significant decrease in our collection rate; specifically, a decrease in the amount we collected per Medicaid patient-the category of payer that increased post ACA. The ACA did allow more uninsured patients access to medical care but was associated with lower IP and OP reimbursements.

Approaches to Distal Upper-Extremity Trauma: A Comparison of Plastic, Orthopedic, and Hand Surgeons in Academic Practice.

BACKGROUND: Hand trauma call duties at university medical centers are traditionally split among plastic surgeons and orthopedic surgeons, frequently without additional fellowship training in hand and upper-extremity surgery. Differences in operative approach between these groups have never been specifically described. The University Health Consortium-Association of American Medical Colleges Faculty Practice Solutions Center database contains comprehensive, factual, billing and coding data from 90 academic medical centers in the United States and can be used to characterize the practice patterns of various academic surgical specialties. OBJECTIVE: To characterize and compare the clinical experience of academic plastic, orthopedic, and hand surgeons in addressing traumatic distal upper extremity injuries (using the Faculty Practice Solutions Center data set). METHODS: Annual data for CPT defined procedures related to traumatic injuries of the nail bed, finger, hand, wrist, and forearm performed by plastic, orthopedic, and hand surgeons during calendar years 2010 to 2013 were included in the study. RESULTS: From 2010 to 2013, the experience of fellowship-trained hand surgeons in treating traumatic distal upper extremity injuries was consistently greater than that of plastic surgeons and general orthopedic surgeons across all categories. Injuries of the nail bed were repaired more frequently by plastic surgeons than orthopedic surgeons (average 1.3 annual procedures per surgeon for plastic surgeons compared with 0.3 for orthopedic surgeons). Fractures and dislocations involving the phalanx and metacarpal were repaired equally by both groups, with plastic surgeons using predominantly percutaneous (38%) or open methods (45% of repairs), and orthopedic surgeons using mostly closed reduction (59% of repairs), splinting, and casting. Fractures and dislocations involving the carpal bones, radius, and ulna were more frequently repaired by orthopedic surgeons (average 23.2 procedures versus 2.6 for plastic surgeons), whereas tendon repairs in all segments were performed more frequently by plastic surgeons (average 13.7 procedures versus 2.5 for orthopedic surgeons). Replantation and repair of neurovascular injuries were exceedingly rare (less than 1 occurrence) in all groups for all years and are not specifically reported in Table 1. Similarly, incision and drainage procedures and decompressive fasciotomies of the distal upper extremity were uncommonly performed and also not included (Table 1 displays the mean annual procedures per surgeon by grouped CPT coded procedures, with overall averages displayed to the right. Figure 1 displays the proportions of intra-articular and extra-articular bony hand injuries treated by closed, open, and percutaneous methods by each specialty). CONCLUSIONS: A large degree of variation exists in the treatment of distal upper extremity injuries, based on specialty service. Hand surgeons, not surprisingly, have the most robust clinical experience, whereas plastic surgeons and orthopedic surgeons each display varying strengths and weaknesses, perhaps a consequence of their respective training.

Management of children with solid organ injuries after blunt torso trauma.

BACKGROUND: Management of children with intra-abdominal solid organ injuries has evolved markedly. We describe the current management of children with intra-abdominal solid organ injuries after blunt trauma in a large multicenter network. METHODS: We performed a planned secondary analysis of a prospective, multicenter observational study of children (<18 years) with blunt torso trauma. We included children with spleen, liver, or kidney injuries identified by computed tomography, laparotomy/laparoscopy, or autopsy. Outcomes included disposition and interventions (blood transfusion for intra-abdominal hemorrhage, angiography, laparotomy/laparoscopy). We performed subanalyses of children with isolated injuries. RESULTS: A total of 12,044 children were enrolled; 605 (5.0%) had intra-abdominal solid organ injuries. The mean (SD) age was 10.7 (5.1) years, and injured organs included spleen 299 (49.4%), liver 282 (46.6%), and kidney 147 (24.3%). Intraperitoneal fluid was identified on computed tomography in 461 (76%; 95% confidence interval [CI], 73-80%), and isolated solid organ injuries were present in 418 (69%; 95% CI, 65-73%). Treatment included therapeutic laparotomy in 17 (4.1%), angiographic embolization in 6 (1.4%), and blood transfusion in 46 (11%) patients. Laparotomy rates for isolated injury were 11 (5.4%) of 205 (95% CI, 2.7-9.4%) at non-freestanding children's hospitals and 6 (2.8%) of 213 (95% CI, 1.0-6.0%) at freestanding children's hospitals (difference, 2.6%; 95% CI, -7.1% to 12.2%). Dispositions of the 212 children with isolated Grade I or II organ injuries were home in 6 (3%), emergency department observation in 9 (4%), ward in 114 (54%), intensive care unit in 73 (34%), operating suite in 7 (3%), and transferred in 3 (1%) patients. Intensive care unit admission for isolated Grade I or II injuries varied by center from 9% to 73%. CONCLUSION: Most children with solid organ injuries are managed with observation. Blood transfusion, while uncommon, is the most frequent therapeutic intervention; angiographic embolization and laparotomy are uncommon. Emergency department disposition of children with isolated Grade I to II solid organ injuries is highly variable and often differs from published guidelines. LEVEL OF EVIDENCE: Prognostic/epidemiologic study, level III; therapeutic study, level IV.

Rise in microsurgical free-flap breast reconstruction in academic medical practices.

BACKGROUND: Previous studies have examined national trends in breast reconstruction, using various data sets demonstrating increases in implant-based reconstruction and decreases in autologous reconstruction. However, academic breast reconstruction practices have never been specifically characterized. The University Health Consortium-Association of American Medical Colleges Faculty Practice Solutions Center database contains comprehensive, factual billing and coding data from 90 academic medical centers in the United States, and has been used to characterize practice patterns of various academic surgical specialties. OBJECTIVE: To describe breast reconstruction trends unique to academic surgical practices, using the Faculty Practice Solutions Center database. METHODS: Annual data for defined breast reconstruction procedures (current procedural terminology codes: 19340, 19342, 19357, 19361, 19364, 19366, 19367, 19369, and 19380) performed by university plastic surgeons during calendar years 2007 to 2013 were included in the study. RESULTS: From 2007 to 2013, a 2-fold increase in the number of breast reconstruction procedures was observed (from a mean of 45.3 to 94.2 procedures per surgeon). During this period, implant-based reconstructions and autologous reconstructions rose in tandem (28.9-44.6 and 11.4-19.3, respectively), with a preserved 2.5:1 ratio between the 2 categories each year. When compared to reconstructions overall, the proportion of both implant reconstruction and autologous reconstruction procedures declined, since revision and other types of reconstructions increased (11% of all reconstructions in 2007 vs 32% in 2013). With regard to autologous reconstruction, microsurgical free flaps (mostly comprised of deep inferior epigastric artery perforator flaps) have supplanted latissimus flaps as the favored modality and comprised 13% to 14% of breast reconstruction cases overall from 2011 to 2013. CONCLUSION: In contrast to national trends, university-based plastic surgeons are performing a growing number of microsurgical free flaps as the preferred method for autologous breast reconstruction. Whereas implant-based reconstructions still predominate in academic practices, the trend of increasing preference toward implant-based reconstructions has slowed in recent years and revision reconstructions are on the rise.

Isolated linear skull fractures in children with blunt head trauma.

BACKGROUND AND OBJECTIVE: Children and adolescents with minor blunt head trauma and isolated skull fractures are often admitted to the hospital. The objective of this study was to describe the injury circumstances and frequency of clinically important neurologic complications among children with minor blunt head trauma and isolated linear skull fractures. METHODS: This study was a planned secondary analysis of a large prospective cohort study in children <18 years old with blunt head trauma. Data were collected in 25 emergency departments. We analyzed patients with Glasgow Coma Scale scores of 14 or 15 and isolated linear skull fractures. We ascertained acute neurologic outcomes through clinical information collected during admission or via telephone or mail at least 1 week after the emergency department visit. RESULTS: In the parent study, we enrolled 43,904 children (11,035 [25%] <2 years old). Of those with imaging studies, 350 had isolated linear skull fractures. Falls were the most common injury mechanism, accounting for 70% (81% for ages <2 years old). Of 201 hospitalized children, 42 had computed tomography or MRI repeated; 5 had new findings but none required neurosurgical intervention. Of 149 patients discharged from the hospital, 20 had repeated imaging, and none had new findings. CONCLUSIONS: Children with minor blunt head trauma and isolated linear skull fractures are at very low risk of evolving other traumatic findings noted in subsequent imaging studies or requiring neurosurgical intervention. Hospital admission for neurologically normal children with isolated linear skull fractures after minor blunt head trauma for monitoring is typically unnecessary.

The modern acute care surgeon: characterization of an evolving surgical niche.

BACKGROUND: Trauma and emergency surgery continues to evolve as a surgical niche. The simple fact that The Journal of Trauma is now entitled The Journal of Trauma and Acute Care Surgery captures this reality. We sought to characterize the niche that trauma and emergency surgeons have occupied during the maturation of the acute care surgery model. METHODS: We analyzed the University Health System Consortium-Association of American Medical Colleges Faculty Practice Solutions Center database for the years 2007 to 2012 for specific current procedural terminology (CPT) codes. This database includes coding and billing data for more than 90 academic medical centers throughout the United States. We analyzed frequency counts and work relative value units (wRVUs) generated for specific codes to characterize the average trauma and emergency surgeon's work experience over time. RESULTS: We found that acute care surgeons generated 42.4% of wRVUs from procedural work and 57.6% from cognitive work. For cognitive work, critical care services generated the most wRVUs per year (25.2% of total), and subsequent hospital care was the most frequently performed activity (1,236.6 codes generated per year). For procedural work, laparoscopic cholecystectomies produced the most wRVUs per year (2.4% of total), and placement of a nontunneled catheter was the most frequently performed procedure (42.2 times per year). The average acute care surgeon performed the following numbers of procedures per year: 29.6 cholecystectomies and 20.0 appendectomies; 7.7 wound vacuum device changes; 5.9 implantation of mesh procedures; 4.9 splenectomies and 0.4 splenorrhaphies; 2.6 perirectal abscess drainage procedures; less than one component separation fascial hernia repair; and less than one video-assisted thoracic surgery. CONCLUSION: The modern acute care surgeon is a hybrid of critical care medicine physician and ever-evolving surgical interventionist. Acute care surgeons continue to do traditional trauma work while increasingly performing acute care surgeries. The work of acute care surgeons serves a growing role and fills a valuable niche in our health care system.

Association between the seat belt sign and intra-abdominal injuries in children with blunt torso trauma in motor vehicle collisions.

OBJECTIVES: The objective was to determine the association between the abdominal seat belt sign and intra-abdominal injuries (IAIs) in children presenting to emergency departments with blunt torso trauma after motor vehicle collisions (MVCs). METHODS: This was a planned subgroup analysis of prospective data from a multicenter cohort study of children with blunt torso trauma after MVCs. Patient history and physical examination findings were documented before abdominal computed tomography (CT) or laparotomy. Seat belt sign was defined as a continuous area of erythema, ecchymosis, or abrasion across the abdomen secondary to a seat belt restraint. The relative risk (RR) of IAI with 95% confidence intervals (CIs) was calculated for children with seat belt signs compared to those without. The risk of IAI in those patients with seat belt sign who were without abdominal pain or tenderness, and with Glasgow Coma Scale (GCS) scores of 14 or 15, was also calculated. RESULTS: A total of 3,740 children with seat belt sign documentation after blunt torso trauma in MVCs were enrolled; 585 (16%) had seat belt signs. Among the 1,864 children undergoing definitive abdominal testing (CT, laparotomy/laparoscopy, or autopsy), IAIs were more common in patients with seat belt signs than those without (19% vs. 12%; RR = 1.6, 95% CI = 1.3 to 2.1). This difference was primarily due to a greater risk of gastrointestinal injuries (hollow viscous or associated mesentery) in those with seat belt signs (11% vs. 1%; RR = 9.4, 95% CI = 5.4 to 16.4). IAI was diagnosed in 11 of 194 patients (5.7%; 95% CI = 2.9% to 9.9%) with seat belt signs who did not have initial complaints of abdominal pain or tenderness and had GCS scores of 14 or 15. CONCLUSIONS: Patients with seat belt signs after MVCs are at greater risk of IAI than those without seat belt signs, predominately due to gastrointestinal injuries. Although IAIs are less common in alert patients with seat belt signs who do not have initial complaints of abdominal pain or tenderness, the risk of IAI is sufficient that additional evaluation such as observation, laboratory studies, and potentially abdominal CT scanning is generally necessary.

Use of the focused assessment with sonography for trauma (FAST) examination and its impact on abdominal computed tomography use in hemodynamically stable children with blunt torso trauma.

BACKGROUND: The aim of this study was to evaluate the variability of clinician-performed Focused Assessment with Sonography for Trauma (FAST) examinations and its impact on abdominal computed tomography (AbCT) use in hemodynamically stable children with blunt torso trauma (BTT). The FAST is used with variable frequency in children with BTT. METHODS: We performed a planned secondary analysis of children (<18 years) with BTT. Patients with a Glasgow Coma Scale (GCS) score of less than 9, those with hypotension, and those taken directly to the operating suite were excluded. Clinicians documented their suspicion for intra-abdominal injury (IAI) as very low, less than 1%; low, 1% to 5%; moderate, 6% to 10%; high, 11% to 50%; or very high, greater than 50%. We determined the relative risk (RR) for AbCT use based on undergoing a FAST examination in each of these clinical suspicion strata. RESULTS: Of 6,468 (median age, 11.8 years; interquartile range, 6.3-15.5 years) children who met eligibility, 887 (13.7%) underwent FAST examination before CT scan. A total of 3,015 (46.6%) underwent AbCT scanning, and 373 (5.8%) were diagnosed with IAI. Use of the FAST increased as clinician suspicion for IAI increased, 11.0% with less than 1% suspicion for IAI, 13.5% with 1% to 5% suspicion, 20.5% with 6% to 10% suspicion, 23.2% with 11% to 50% suspicion, and 30.7% with greater than 50% suspicion. The patients in whom the clinicians had a suspicion of IAI of 1% to 5% or 6% to 10% were significantly less likely to undergo a CT scan if a FAST examination was performed: RR, 0.83 (0.67-1.03); RR, 0.81 (0.72-0.91); RR, 0.85 (0.78-0.94); RR, 0.99 (0.94-1.05); and RR, 0.97 (0.91-1.05) for patients with clinician suspicion of IAI of less than 1%, 1% to 5%, 6% to 10%, 11% to 50%, and greater than 50%, respectively. CONCLUSION: The FAST examination is used in a relatively small percentage of children with BTT. Use increases as clinician suspicion for IAI increases. Patients with a low or moderate clinician suspicion of IAI are less likely to undergo AbCT if they receive a FAST examination. A randomized controlled trial is required to more precisely determine the benefits and drawbacks of the FAST examination in the evaluation of children with BTT. LEVEL OF EVIDENCE: Prognostic and epidemiologic study, II.

Practice patterns of academic general thoracic and adult cardiac surgeons.

OBJECTIVE: We hypothesized that academic adult cardiac surgeons (CSs) and general thoracic surgeons (GTSs) would have distinct practice patterns of, not just case-mix, but also time devoted to outpatient care, involvement in critical care, and work relative value unit (wRVU) generation for the procedures they perform. METHODS: We queried the University Health System Consortium-Association of American Medical Colleges Faculty Practice Solution Center database for fiscal years 2007-2008, 2008-2009, and 2009-2010 for the frequency of inpatient and outpatient current procedural terminology coding and wRVU data of academic GTSs and CSs. The Faculty Practice Solution Center database is a compilation of productivity and payer data from 86 academic institutions. RESULTS: The greatest wRVU generating current procedural terminology codes for CSs were, in order, coronary artery bypass grafting, aortic valve replacement, and mitral valve replacement. In contrast, open lobectomy, video-assisted thoracic surgery wedge, and video-assisted thoracic surgery lobectomy were greatest for GTSs. The 10 greatest wRVU-generating procedures for CSs generated more wRVUs than those for GTSs (P<.001). Although CSs generated significantly more hospital inpatient evaluation and management (E & M) wRVUs than did GTSs (P<.001), only 2.5% of the total wRVUs generated by CSs were from E & M codes versus 18.8% for GTSs. Critical care codes were 1.5% of total evaluation and management billing for both CSs and GTSs. CONCLUSIONS: Academic CSs and GTSs have distinct practice patterns. CSs receive greater reimbursement for services because of the greater wRVUs of the procedures performed compared with GTSs, and evaluation and management coding is a more important wRVU generator for GTSs. The results of our study could guide academic CS and GTS practice structure and time prioritization.

Sustainability and success of the acute care surgery model in the nontrauma setting.

BACKGROUND: The use of an acute care surgical model has been shown to improve patient care and efficiency. We propose that it is possible to apply this model to emergency general surgery patients at a nontrauma hospital. With this acute care surgery service, no change in the quality of care will occur, and improvements in quality, cost, and outcomes may be achieved and sustained. STUDY DESIGN: A retrospective review was performed of all emergency surgery operations performed at a tertiary referral community hospital without a trauma service. Data were collected from 1 year before and each year up to 4 years after the implementation of an acute care surgical (ACS) service. RESULTS: There were fewer overall complications with ACS (21% to 12%, p < 0.0001), and a shorter length of stay (6.5 days to 5.7 days, p = 0.0016). Hospital costs fell from $12,009 to $8,306 (p < 0.0001). Post-appendectomy complications decreased (13% to 3.7%, p < 0.0001), length of stay was shorter (3.0 to 2.3 days, p < 0.0001), and hospital costs decreased from $9,392 to $5,872 (p < 0.0001). Post-cholecystectomy complications decreased (21% to 9%, p = 0.012), length of stay was shorter (5.3 to 3.8 days, p = 0.0004), and hospital costs decreased from $12,526 to $9,348 (p < 0.0001). CONCLUSIONS: An acute care surgery service can be successfully implemented at a nontrauma hospital. The improvements seen in outcomes and finances are sustainable over time. This sort of coordinated, consistent care is successful and allows alignment of the goals of surgeons, hospitals, and patients.

Risk of traumatic brain injuries in children younger than 24 months with isolated scalp hematomas.

STUDY OBJECTIVE: We aimed to determine the association between scalp hematoma characteristics and traumatic brain injuries in young children with blunt head trauma who have no other symptoms or signs suggestive of traumatic brain injuries (defined as "isolated scalp hematomas"). METHODS: This was a secondary analysis of children younger than 24 months with minor blunt head trauma from a prospective cohort study in 25 Pediatric Emergency Care Applied Research Network emergency departments. Treating clinicians completed a structured data form. For children with isolated scalp hematomas, we determined the prevalence of and association between scalp hematoma characteristics and (1) clinically important traumatic brain injury (death, neurosurgery for traumatic brain injury, intubation >24 hours for traumatic brain injury, or positive computed tomography (CT) scan in association with hospitalization ≥2 nights for traumatic brain injury); and (2) traumatic brain injury on CT. RESULTS: Of 10,659 patients younger than 24 months were enrolled, 2,998 of 10,463 (28.7%) with complete data had isolated scalp hematomas. Clinically important traumatic brain injuries occurred in 12 patients (0.4%; 95% confidence interval [CI] 0.2% to 0.7%); none underwent neurosurgery (95% CI 0% to 0.1%). Of 570 patients (19.0%) for whom CTs were obtained, 50 (8.8%; 95% CI 6.6% to 11.4%) had traumatic brain injuries on CT. Younger age, non-frontal scalp hematoma location, increased scalp hematoma size, and severe injury mechanism were independently associated with traumatic brain injury on CT. CONCLUSION: In patients younger than 24 months with isolated scalp hematomas, a minority received CTs. Despite the occasional presence of traumatic brain injuries on CT, the prevalence of clinically important traumatic brain injuries was very low, with no patient requiring neurosurgery. Clinicians should use patient age, scalp hematoma location and size, and injury mechanism to help determine which otherwise asymptomatic children should undergo neuroimaging after minor head trauma.

Small community hospitals programs affiliation with university programs; "lessons learned" in 28-year successful affiliation.

OBJECTIVE: Community hospitals affiliation with university hospitals in post graduate surgical education is essential for the 2 types of training programs. Many factors affect the success of the affiliation process. Additionally, various pitfalls and challenges are encountered. The goal of this work is to study the lessons learned in 28 years successful affiliation. DESIGN/SETTING: small community hospital affiliation with university program for 28 years. PARTICIPANTS: surgery residency programs in small community hospital and university hospital. RESULTS: successful affiliation for 28 years between community hospital and university program.

Extremity soft tissue tumor surgery by surgical specialty: a comparison of case volume among oncology and non-oncology-designated surgeons.

INTRODUCTION: We sought to characterize the extent of extremity soft tissue tumor (ESTT) resections among surgical specialties, hypothesizing that substantial variation exists in the number of ESTT resections performed by specialty. METHODS: We queried the UHC-AAMC database for data from 85 institutions for years 2007-2009. We abstracted data on total number of musculoskeletal (MSK) procedures, number of subcutaneous (SQ), deep, and malignant ESTT resections, and anatomic site of resection. Data were available for 4,682 practitioners including the following specialties: general surgery (GS, N = 2,195), plastic surgery (PS, N = 792), surgical oncology (SO, N = 533), general orthopedics (GO, N = 1,079), and orthopedic oncology (OO, N = 83). RESULTS: The mean number of all MSK procedures performed per year was 19.0 ± 2.3 GS, 179.6 ± 3.0 PS, 32.4 ± 6.2 SO, 798.6 ± 115.4 GO, and 482.9 ± 6.5 OO (P = 0.001). SQ ESTT resections per year were similar among specialties (1.7 ± 0.3 GS, 2.7 ± 0.3 PS, 2.4 ± 0.4 SO, 1.7 ± 0.5 GO, 4.7 ± 0.2 OO), while deep and malignant resections were more likely performed by OO (combined deep and malignant: 0.9 ± 0.1 GS, 2.0 ± 0.4 PS, 9.9 ± 0.6 SO, 5.8 ± 0.3 GO, and 63.6 ± 8.1 OO, P = 0.001). Adjusting for number of physicians in the database, of the total deep and malignant ESTT resections, 9.4% were performed by GS, 7.7% by PS, 26.0% by SO, 30.8% by GO, and 26.0% by OO. CONCLUSION: Nearly 50% of deep and malignant ESTT resections are performed by non-oncology-designated surgeons. Approximately 17% are performed by practitioners who complete an average of one to two of these procedures per year. These findings may have significant implications for quality of care in soft tissue tumor surgery.

A multicenter study of the risk of intra-abdominal injury in children after normal abdominal computed tomography scan results in the emergency department.

STUDY OBJECTIVE: We determine whether intra-abdominal injury is rarely diagnosed after a normal abdominal computed tomography (CT) scan result in a large, generalizable sample of children evaluated in the emergency department (ED) after blunt torso trauma. METHODS: This was a planned analysis of data collected during a prospective study of children evaluated in one of 20 EDs in the Pediatric Emergency Care Applied Research Network. The study sample consisted of patients with normal results for abdominal CT scans performed in the ED. The principal outcome measure was the negative predictive value of CT for any intra-abdominal injury and those undergoing acute intervention. RESULTS: Of 12,044 enrolled children, 5,380 (45%) underwent CT scanning in the ED; for 3,819 of these scan the results were normal. Abdominal CT had a sensitivity of 97.8% (717/733; 95% confidence interval [CI] 96.5% to 98.7%) and specificity of 81.8% (3,803/4,647; 95% CI 80.7% to 82.9%) for any intra-abdominal injury. Sixteen (0.4%; 95% CI 0.2% to 0.7%) of the 3,819 patients with normal CT scan results later received a diagnosis of an intra-abdominal injury, and 6 of these underwent acute intervention for an intra-abdominal injury (0.2% of total sample; 95% CI 0.06% to 0.3%). The negative predictive value of CT for any intra-abdominal injury was 99.6% (3,803/3,819; 95% CI 99.3% to 99.8%); and for injury undergoing acute intervention, 99.8% (3,813/3,819; 95% CI 99.7% to 99.9%). CONCLUSION: In a multicenter study of children evaluated in EDs after blunt torso trauma, intra-abdominal injuries were rarely diagnosed after a normal abdominal CT scan result, suggesting that safe discharge is possible for the children when there are no other reasons for admission.

Identifying children at very low risk of clinically important blunt abdominal injuries.

STUDY OBJECTIVE: We derive a prediction rule to identify children at very low risk for intra-abdominal injuries undergoing acute intervention and for whom computed tomography (CT) could be obviated. METHODS: We prospectively enrolled children with blunt torso trauma in 20 emergency departments. We used binary recursive partitioning to create a prediction rule to identify children at very low risk of intra-abdominal injuries undergoing acute intervention (therapeutic laparotomy, angiographic embolization, blood transfusion for abdominal hemorrhage, or intravenous fluid for ≥2 nights for pancreatic/gastrointestinal injuries). We considered only historical and physical examination variables with acceptable interrater reliability. RESULTS: We enrolled 12,044 children with a median age of 11.1 years (interquartile range 5.8, 15.1 years). Of the 761 (6.3%) children with intra-abdominal injuries, 203 (26.7%) received acute interventions. The prediction rule consisted of (in descending order of importance) no evidence of abdominal wall trauma or seat belt sign, Glasgow Coma Scale score greater than 13, no abdominal tenderness, no evidence of thoracic wall trauma, no complaints of abdominal pain, no decreased breath sounds, and no vomiting. The rule had a negative predictive value of 5,028 of 5,034 (99.9%; 95% confidence interval [CI] 99.7% to 100%), sensitivity of 197 of 203 (97%; 95% CI 94% to 99%), specificity of 5,028 of 11,841 (42.5%; 95% CI 41.6% to 43.4%), and negative likelihood ratio of 0.07 (95% CI 0.03 to 0.15). CONCLUSION: A prediction rule consisting of 7 patient history and physical examination findings, and without laboratory or ultrasonographic information, identifies children with blunt torso trauma who are at very low risk for intra-abdominal injury undergoing acute intervention. These findings require external validation before implementation.

Flexion and extension radiographic evaluation for the clearance of potential cervical spine injures in trauma patients.

BACKGROUND: Flexion and extension radiographs are often used in the setting of trauma to clear a cervical spine injury. The utility of such tests, however, remains to be determined. We hypothesized that in patients who underwent a negative computed tomography (CT) cervical spine scan, flexion and extension radiographs did not yield useful additional information. METHODS: We conducted a retrospective chart review of all patients admitted to a Level I trauma center who had a negative CT scan of the cervical spine and a subsequent cervical flexion-extension study for evaluation of potential cervical spine injury. All flexion-extension films were independently reviewed to determine adequacy as defined by C7/T1 visualization and 30° of change in the angle from flexion to extension. The independent reviews were compared to formal radiology readings and the influence of the flexion-extension studies on clinical decision making was also reviewed. RESULTS: One thousand patients met inclusion criteria for the study. Review of the flexion-extension radiographs revealed that 80% of the films either did not adequately demonstrate the C7/T1 junction or had less than 30° range of motion. There was one missed injury that was also missed on magnetic resonance imaging. Results of the flexion-extension views had minimal effects on clinical decision making. CONCLUSION: Adequate flexion extension films are difficult to obtain and are minimally helpful for clearance of the cervical spine in awake and alert trauma patients.